Help In Picking Through The Medicare Maze

Guide Helps People With Medicare

August 19, 1991|By FRANK SPENCER-MOLLOY; Courant Medical Writer

Arguably one of the least useful things Margie Groom tells her audiences struggling to understand Medicare is that if you are en route to Alaska and driving through -- but not vacationing in -- Canada, and you become ill, the U.S. insurance program for the elderly will pay your Canadian hospital and doctor bills.

Never mind that the only medical-related bills Canadians of any age in that country ever see are small fees for the use of the TV in their hospital rooms. Canada has a national health plan; the United States does not. And Margie Groom is in business these days because so few Americans comprehend the mishmash of benefits, loopholes and exclusions that make up this nation's system of health care for those 65 and older.

Groom works for the Center for Public Representation, a non-profit consumer group based in Madison, Wis. She was in Manchester last Tuesday, working with the American Association of Retired Persons, or AARP, on ways to better help older people in the Hartford area negotiate the Medicare maze.

That, in fact, is part of the title of a book Groom co-wrote for the center, "Mastering the Medicare Maze," which was updated this year to reflect rule changes.

Groom was at the Arbors at Hop Brook, a retirement community, to tutor 39 volunteers belonging to AARP's Medicare/Medicaid Assistance Program. Steeped in the ins and outs of Medicare, the volunteers in turn will fan out to senior centers, churches and libraries to troubleshoot and answer questions from Medicare recipients, explain exclusions in their doctor and hospital bills, suggest how to shop for medigap insurance and explain how to appeal a denial of benefits.

Their services are free and available to non-AARP members, said Allen Gross, the program's assistant state coordinator.

In her travels throughout the country, Groom said, she gets feedback on the problems that plague Medicare recipients most.

These days she is hearing fewer paperwork problems. Medicare recently required physicians to forward the paperwork (or an electronic version of paperwork) directly to the private carriers who handle Medicare accounts.

Groom also hears less about hospitals, which since 1983 have been obliged to accept a fixed payment, preset according to diagnosis, for a patient. She is hearing more confusion about medical care provided outside the hospital, which contrary to most people's expectations, Medicare often pays for.

On Tuesday Groom spent the better part of an hour explaining to her class how hospice care, which is for the terminally ill, is covered if the physician's prognosis is that the patient has six months or less to live. She outlined how other kinds of skilled care provided at home and in nursing homes also are covered. And she explained how those DRGs, or diagnosis-related groups that limit hospital payments, work and why they were adopted amid growing signs that the Medicare trust fund was going broke.

"Until 1983, doctors and hospitals could keep a patient as long as they wanted and perform all these tests," she said. "The bigger the bill, the bigger the check" they got from Medicare.

But the system Medicare set out to fix has undergone further refinement, and now DRGs can be adjusted for a patient's age and other medical complications, even those that occur after release from the hospital, she told the group.

The biggest complaints Groom still hears come from patients who get stuck with huge doctor bills they thought Medicare was supposed to pay.

Some are simple victims of confusion, Groom said. "They think that because a doctor accepts Medicare assignment, they don't owe anything." Not true. Medicare pays 80 percent of the bill; the patient pays the other 20 percent.

But the equation doesn't end there. In many cases, doctors who accept Medicare can tack on additional charges, which the patient is responsible for. Connecticut has a program, ConnPace, that protects elderly with low incomes, but Massachusetts, which has tougher insurance regulation, requires all physicians to participate in Medicare and does not allow the maneuver, called "balance billing."

Doctors who refuse to participate in Medicare or who balance-bill say the government's reimbursements are not enough for them to meet their overhead.

Other patients, Groom said, are blindsided in the hospital when they are referred to specialists they didn't know refuse Medicare. They are later surprised to find they are responsible for all or part of that bill.

A "real culprit is the anesthesiologist," she said, whose patients are literally a captive audience and who may in some towns and hospitals have a monopoly.

Since January the federal government has limited charges for many specialists to 40 percent to 50 percent above what Medicare pays.

But some doctors are flouting the law, and the explanation of benefits sent to Medicare recipients does not explicitly cite what the physician is allowed to charge, she said. Patients are confused and do not know how to work the system, she said.